Combo with "ATI COMPREHENSION A/B RATIONALES" and 1

other (has poss pharm questions??)

Study online at quizlet.com/_1n1omw
1.

what is montelukast
(singular) for?

a leukotriene modifier, and is taken

on a regular basis, once a day, and
not prn, and is not used for exercise
induced asthma

16.

where should drops be

instill into?

into the conjuctival sac

17.

what is a positive way of

dealing with a terminal
illness?

"remembering things they

used to do together"

2.

what does advance

directives contain?

written instructions regarding end of

life care

18.

3.

what is the greatest

risk to a pt receiving
hemodialysis?

disequilibrium syndrome as a result

of rapid loss of fluids and decrease
bun

what are normal findings

after a colonoscopy?

abd cramping
fatigue
passage of liquid stools

19.

4.

what is the clinical

manifestation of
disequilibrium?

restlessness and decreased level of

consciousness

what are unexpected

finding after a colonoscopy?

guarding- can indicate bowel

perforation

20.

what do you do if an order

is questioned?

what are expected

findings in
hemodialysis?

elevated temp
weight loss
decreased bp

the nurse should record

seeking clarification from the
provider

21.

what should pt with

gastritis eat?

what should the

nurse do when a pt
feels lightheaded and
begins to fall?

spread feet apart and extend one

leg for the pt to slide down while
lowering the pt to the floor

a well balanced diet, they

should keep a record of foods
that cause discomfort, pts can
modify their diet accordingly

22.

what is the cause

autonomic dysreflexia?

bladder distention

what are the

characteristics of a pt
with dependent
personality disorder?

they have problems making

everyday decision without input
from others

23.

what are s/s of icp?

restlessness
change in LOC

24.

what is late s/s of ICP?

a pregnant pt who is
bleeding is always?

priority

widening pulse
decerebrate posturing

25.

what should a
pregnant pt with
urgency and frequent
urination do?

should perform kegel exercises

when can a child with

varicella(chickenpox)
return school?

the child can return to school

when the blisters are dry and
no longer drained (scabbed
over)

26.

what should a
pregnant pt with
odorless vaginal
mucus do?

practice good hygiene, use perineal

pads

what is an appropriate
behavior of a pt with hx of
violence?

pt will avoid violence

provoking situations

27.

what is a skin cancer

prevention?

pts should use sunscreen that

protects against uva and uvb

11.

a pregnant pt with
edema of the ankles
do?

avoid prolonged standing, to wear

support hose, and rest through out
the day with legs/hip elevated

28.

what is the first thing you

should do with excessive
lochial discharge?

perform a fundal massage

12.

when should a
colostomy bag be
changed?

when is 1/3 -1/2 full

29.

13.

how large should the

opening of the stoma
pouch be?

no larger than 1/4 inch

what is the nurse

responsibility of the nurse
when witnessing the pts
signature on an informed
consent?

that the pt is fully informed

and understands the
procedure befor signing the
consent form

30.

what should the pt

with a colostomy
avoid?

the use of moisturizers, which will

decrease the adherence of the
pouch to the skin

who are at greater risk for

std?

females because of increased

vascularity to the vagina

31.

NO

what should the pt

do with the pouch
removing it?

they should empty the pouch to

avoid spilling the effluent on to the
skin

does trichomonas vaginalis

increased the risk for
cervical cancer?

5.

6.

7.

8.

9.

10.

14.

15.

32.

Gonorrhea can lead to?

pelvic inflammatory disease and

tubal scarring and can result in
infertility

33.

what should you do

with postmortem
care?

always check about religious

practices prior to body preparation
in order to honor fam wishes

34.

what can you not give

to a pt with thickened
liquids?

no ice chips
no water
no icepops

35.

what can a pt with

thickened liquids
have?

oatmeal

what should a pt do
with incentive
spirometer?

they should elevate the cylinder by

inhaling deeply
assume semi fowlers or high
fowlers position

36.

37.

in order to maintain
sterile technique what
should the nurse do?

should open all sterile packages

prior to donning sterile gloves

38.

what is psycho-motor
learning?

have the pt demonstrate back the

procedure

what places a newborn

at risk for respiratory
depression?

administration of an opioid
analgesic
exa: fentanyl (sublimaze)

40.

what is an effective
method of bowel
retraining?

anal stimulation with a gloved

finger after the evening meal, it will
help stimulate the gastrocolic reflex

41.

when inserting an NG
tube?

the nurse should insert the tube

into the airway that is patent and
has greater airflow

42.

what technique should

be NG tube insertion?

clean technique

43.

if NG tube meets
resistance?

the nurse should rotate the tube

without forcing it past the area of
resistance

39.

44.

45.

46.

47.

what kind of lubricant

should be used during
NG tube insertion?

water- based lubricant NOT

petroleum jelly

what is pediculosis
capitis management?

store child's clothing in a separate

cubicle at school
boil brushes and combs in water
for 10 mins
dry bed lines and clothing in a hot
dryer for at least 20 mins

what can visual

disturbances indicate?

preeclampsia

what is expected 24 hrs

after surgery?

hypo active bowel sounds

pain

48.

what is an abnormal
finding 24 hrs after surgery?

low HGB

49.

what must be done in

bucks traction?

the pt must be in proper

alignment
boots are secured by 3 straps,
around pt leg
weights must hang freely
footplate is resting 15.24 cm
(6inches) from the footboard

50.

what does pts with

delirium demonstrate?

a fluctuating LOC often at night

or in am

51.

pt with dementia
demonstrate?

difficulty finding correct words

to use

52.

pt with anxiety disorders

demonstrate?

obsessive behavior

53.

how would the nurse

determine progression of
ascites?

abdominal girth should be

measured daily

54.

what is a food high in

potassium?

cantaloupe

55.

what is an indication of
peripheral venous disease?

brown pigmentation around

ankles

56.

what is indication of
peripheral arterial disease?

intermittent, leg muscle pain

57.

what is some skin care for

pts on radiation therapy?

pat area when drying

use hand to wash
do not use sunscreen

58.

what can hydromorpone

cause?

urinary retention

59.

what does bethanechol

(urecholine) causes?

it stimulates urinary out put

60.

how is nystatin best

absorb?

if given 1 hour before or after a

feeding

61.

what is a sign that a

newborn has finished
eating?

a slowed suck/swallow pattern

is a sign that the newborn is
finished eating

62.

what not to do when

breastfeeding?

is not necessary for the entire

areola be in the mouth
each feeding should start at
the opposite breast
do not push back of newborns
head-toward the nipple

63.

what should be included in

a stool specimen?

visible blood, pus, or mucus

64.

what is the first action in

an infiltrated IV?

to d/c the saline lock

65.

what is the first action

when preparing to do a
dressing change?

to determine the pts level of

pain

66.

what should a with

hemonymous hemionopsia
with right visual field, what
will help pt eat better?

the pt should turn head to

the right to see all food on
tray

67.

what are some side effect for

theophylline (theo-dur)?

is used to prevent
wheezing,sob, chest
tightness in asthma
irregular pulse and
dysrhythmias
seizures
anxiety
urinary frequency
anorexia
n/v
diarrhea

68.

what should you do when

given enoxaparin (lovenox)?

it should be injected SUBQ

do not aspirate
do not massage
do not inject in same area

69.

what is the babinski reflex?

stroke sole of the foot

upward, toward the great
toe

70.

what is the moro reflex?

startle the infant by

clapping hands`

71.

what is the stepping reflex?

hold infant upright and

allow one foot to touch
tables surface

72.

what is the palmer grasp

reflex?

place an object in the palm

of infant hand

73.

what should you do when

catheterizing a male pt?

pt should be place in
supine position
penis should be at 90
degree angle
retract the foreskin and
clean the glans prior to
catherization

what color is the meconium?

it is the first stool passed

and it is dark green and
viscous

what is an inportant thing to

ask when pt having cardiac
catherization?

if pt allergic to iodine

76.

what should be done with

nitroglycerin (nitrostat)?

if pt continues to have pain

after taking 1 tab, they
should call 911 and take a
second tab

77.

what is normal after taking a

nitroglycerin (nitrostat) tab?

h/a
change positions slowly
it should be kept in
original, dark colored
bottle to avoid light
exposure

74.

75.

78.

what to do for
restrains use?

observe skin condition before applying

restrains
use a quick release knot to secure the
restraints
belt restrains should be placed over pts
waist
able to insert two fingers under restraints
do not use all four side of rails to restrain
pt

79.

what would
indicate an
active peristalsis?

the presence of vowel sounds

80.

what does pt
with COPD have?

increased metabolism due to work of

labored breathing
they have dry mouth/thick mucus
constipation
decreased peristalsis

81.

how to use a
cane?

pt should hold cane on the stronger side

of the body
place it forward 6-10 inches and move his
weaker leg forward to the cane
distributing his weight between the cane
and the stronger leg
then he should move the stronger leg
forward beyond the cane and distribute
his weight between the cane and weaker
leg

82.

what does the

use of cardiac
catherization
required?

that the pt have normal renal functions

for excretion of the dye

83.

how should
drops be apply?

the nurse should apply gently pressure

to the inner canthus of the eye for 30-60
seconds

84.

what are
hyperthyroidism
findings?

tachycardia

85.

what are
hypothyroidism
findings?

cold intolerance
constipation
brittle hair

86.

how much
should infants
grow?

1 inch per month, during the first 6

months
they should be able to double their birth
weight between 4-6 months of age
and gain approximately 150-210 (about
5-7oz) per week

87.

what should you

do when
evaluating an
infant?

the nurse should measure ht/wt

separately, and not combine

88.

what can reduce the anti

hypertensive effect of anti
hypertensives?

ibuprofen (advil) or any

NSAIDS

89.

what is the first action

when IV pump alarm is
beeping?

to observe the iv site for

infiltration or phlebitis

90.

how are normal bowel

sounds?

high pitched, irregular gurgles

that occur every 5-15 seconds,
in a rage of 5-30 per/min

91.

what is hypoactive?

infrequent less than 5/min

92.

what is hyperactive?

every 3 seconds or greater

93.

what is actinic keratosis?

a pre-malignant lesion
flat, scaly area with red edges

94.

what are cherry

angiomas?

bright red, raised spots

(expected skin changes with
aging)

95.

what does a change in

color mole indicate?

indicates skin cancer

96.

what happens in passive

ROM?

the pt does not actively

participates
the nurse should support the
pts extremities distal and
proximal to the joints to
facilitate passive ROM

what do you do when

inserting a urinary
catheter, and urine is
seen in the tubing?

the catheter should be

advance another 2.5-5 cm to
ensure that the balloon is
inflated in the bladder

98.

what to do when
addressing pt dilemma?

determine the facts related to

dilema
identify possible solutions
consider clients wishes

99.

what should a pt with

peripheral vascular
disease do?

walk until feel pain, rest for 3

min and continue until tired
should sit with legs in a
dependent position

100.

what are s/s of a detached

retina?

photopsia= bright flashes of

light

101.

what are s/s of macular

degeneration?

loss of peripheral vision

102.

what is a normal s/s of

aging?

presbyopia= difficulty focusing

on close objects

103.

what should a pt with DM

and influenza report?

temp higher than 101.5 or

greater for 24 hours

104.

what should be done

with pts with closed head
injury?

should be log roll

only suction on prn basis
maintain HOB at least 30
degrees
do not use an incentive
spirometer ICP might go up

97.

105.

what should a pt with

cardiac catherization
experience?

they should drink adequate

fluids
may need to cough during
test
may experience a feeling of
heat "hot flash"
only need bed rest for 4-6
hours

106.

what should pt with COPD

do?

should perform pursed- lip

breathing
alternate activities with rest
eat high protein snacks
practice relaxation
techniques

107.

turp care?

monitor pt for fluid volume

over load
remind pt that they will feel
urge while catheter is in
place
calculate urinary out put
every 2 hours
measure pain level every 2-3
hours
pt should get up to a chair
asap, risk for dvt

108.

how to administer ear drops

to children under 3 yrs?

pull pinna down and back

109.

how will ventricular

fibrilation look on ekg?

irregular rate without P

waves, bizarre and variable
QRS

110.

what are sinus tachycardia

look on EKG?

regular rate greater than

100/min normal P and QRS
waves

111.

atrial ventricular (AV) block

look on EKG?

regular rate between 60100/min with extended PR

intervals

112.

premature atrial
contractions look on EKG?

irregular rate with ectopic

atrial beats earlier than
expected

113.

what are s/s of febrile

transfussion reaction?

chills

114.

what are s/s of circulatory

overload transfussion
reaction?

bounding pulse and

hypertension

115.

what are s/s of hemolytic

transfussion reaction?

lower back pain

116.

what foods are rich in iron?

red meats, liver

117.

what to look for in HCTZ

(Hydrodiuril)?

flunctuation in weight
encourage increase of
potassium
should be taken with food or
right after a meal

118.

what are s/s of

anaphalictic
reactions?

increased respiratory effort

hypotension
bronchoconstriction (laryngeal
stridor)

119.

what does
benzodiazepines
(lorazepam/ativan)
causes?

lethargic and somnolent

what are pt with

preclampsia at risk
for?

seizures

how should the

formula be to prevent
gastric cramping in
an enteral feeding?

administer the formula at room

temp

what is a s/s of
bulemia nervosa?

hemoptysis

123.

what is a s/s of
anorexia nervosa?

amenorrhea
acrocynosis

124.

what are
interventions for a
salem sump tube?

the most common ng tube it is a

double lumen (two-channeled) it
irrigates the stomach and removes
fluid and gas from stomach.
-pt should be reposition every 2
hours to promote emptiying of
stomach content
-set suction 80-100
-never clamp air vent
pt should be NPO

what might cause dry

skin in older adults?

a decrease in elasticity of the skin

which is an expected change
associated with aging

120.

121.

122.

125.

126.

what is a
bronchoscope?

a tube that allows the doctor to see

in the lungs and airways and
remove objects

127.

what are nursing

interventions for pts
with dementias?

should encourage verbal praise

do not exceed 20 mins in tub
may not be able to follow direction
they should not disrobe until right
before entering the bath to prevent
chilling

128.

129.

what to do with
ankle sprain?

what promotes
venous return?

check for pedal edema

wrap with a compression dressing
apply ice
elevate

130.

what is an expected PR
interval?

should be 0.12 to 0.20 seconds

it should be one P wave prior to
each QRS complex
an expected QRS duration is 0.04
to 0.10 second
an expected ventricular rate of 60
to 100/min

131.

what are s/s of

atorvastatin (lipitor)
side effects?

muscle weakness which can lead

to rhabdomyolysis, report muscle
cramps, pain or tenderness

132.

when should keflex

(cephalexin) not be
given?

if pt has PCN allergy

133.

what will facilitate

understanding in a pt
with anxiety?

the use of short, concise sentenses

because they have difficulty
concentrating

134.

what should be done

to pts with expressive
aphasia?

give them a picture board, or pen

and paper, because pt cannot
verbally express needs or wants
should use simple statements
and speak normal voice

135.

what are risk factors

for colorectal cancer?

obesity
high consumption of alcohol
cigaret smoking
high protein diet
older pt
fam hx of colon cancer/ polyps
hx of gastrectomy and
inflammatory bowel disease

136.

what is given for long

term alcohol abuse?

disulfiram (antabuse), which is an

adversion therapy

137.

what is a bladder scan?

it is a non invasive procedure, and

pt should not experience
discomfort
not a sterile procedure
no consent necessary

138.

how would the nurse

explain a procedure to
a school age child?

using simple diagram

139.

what does concave

shape nails indicate?

emphysema, prolonged
hypoxemia

140.

how many grams of

protein does peanut
butter contains?

7g

141.

what do you do with a

boggy uterus?

promote involution of the uterus,

massaging the fundus because of
hemmorhage

142.

what position is best

for COPD pt?

orthopnea position because it

increases lung expansion

using sequential compression

device

143.

phototherapy
risks?

dehydration
report decreased urine output
infant may sleep longer
should be kept on a regular feeding
schedule of every 3-4 hrs
may have loose green stool

144.

what to teach
with hepatitis B?

pt should use own utensils and dishes

avoid tylenol (acetaminophen)

145.

what should you

teach a pt about
exercising?

they should warm up for atleast 5 mins

first

what should the

nurse avoid when
placing ekg lodes?

avoid scar tissue

post
bronchoscopy
care?

pt should not eat until gag reflex is

checked
blood in sputum is expected
have a ride home
report horseness or wheezing

146.

147.

what to do with a
stage 5 alzheimers
diasease pt?

increase stress level, provide a variety

of foods that the pt is able to eat by
himself to maintain independence

149.

what does
metoprolol affect?

heart rate is a beta adrenergic

antagonist

150.

car seat?

should be secure with a seat belt

151.

where do we do
blood draws?

in the antecubital fossa

152.

crutch teaching?

instruct pt to hold crutches on the side

opposite the injured leg, when sitting to
improve balance and prevent falls

153.

antidepressants
(elavil)
amitriptyline?

pt may not feel better for 7 to 28 days

and may not experience full effect for 6
to 8 weeks

154.

what should pt
with leukemia not
have in the room?

fresh flowers

155.

what is an
indication of
hydration status?

mucus membranes

156.

what is a low
sodium food?

canned peaches

157.

what is high
sodium foods?

wheat crackers
lean ham
cottage cheese

158.

how often is a
tetanus booster?

every ten years

159.

what are some

risk for fall
findings?

the pt walks barefoot

medications stored on top shelf

148.

160.

what is the greatest

risk for a
thyroidectomy?

hypocalcemia with tingling around

the mouth

161.

what are strategies

for teaching
toddlers?

picture books and simple words

162.

what are strategies

for teaching
preschoolers?

role playing/ short stories

163.

what are strategies

for teaching school
age children?

discussing and participating in

hands on demonstration

164.

what are strategies

for teaching
adolescents?

collaborative process/ problem

solving

165.

what is priority in
palliative care?

pharmacological pain management

166.

what should
peritoneal fluid in
dialyses look like?

bloody, clear, straw color

167.

what color should

peritoneal fluid not
look like?

cloudy or opaque, this might means

infections

168.

what is the glascow

coma scale?

motor response

169.

what are s/s of IV

infiltration?

pallor surrounding the infusion site

170.

what is a s/s of
phlebitis?

redness along the vein

171.

what is a s/s of an
extravasation?

tissue sloughing

172.

what to do with a
child with rotavirus?

the diaper should fit snuggly

avoid using a rectal thermometer
apply skin barrier
they are NOT contagious

173.

where should the

chest tube be placed?

below the level of the pts chest

174.

what should be done

with a pen rose
drain?

a safety pin is placed at the distal

end of the drain

175.

what to do with a
colonoscopy?

should not take NSAIDS 1 week

prior
should be NPO 6-8 hours before

176.

what to report with

albuterol (proventil)?

tremors

177.

what should the

nurse do when
removing a pt IV
catheter?

the nurse should maintain the

catheter parallel to the vein to
reduce the risk of trauma to the
vein

178.

what will the child

need prior to an IV
urography (IVP)?

the child will need to have a soapsud

enema administered before the
procedure to assist in visualization of
the kidneys, ureters, and bladder

190.

how is mono
(infectious
mononucleosis)
acquired?

direct contact with droplets of

saliva of an infected person

179.

what diet should

the child with
nephrotic syndrome
be in?

low sodium diet to assist with diuresis

of extracellular fluid

191.

how long after giving

insulin should a nurse
check for
hypoglycemia?

4-14 after administration of NPH

(novolin N) insulin

180.

what is normal
findings in a turp?

yellow urine with red sediment

192.

pt should rinse mouth immediately

after taking med

181.

what is abnormal
finding in a TURP?

LOWER ABD CRAMPING

BLOODY URINE WITH LARGE CLOTS
INCREASED BLADDER SPASMS

what should the pt do

after taking iron
preparation?

193.

in respiratory acidosis
what is elevated?

the Paco2 is elevated greater than

45

what pt should not

take cephalexin
(Keflex)?

pts with PCN allergy

194.

what is the first thing a

pt with prosthesis do?

applied immediately the prosthesis

after waking

195.

what should be used

to clean the inner
cannula of a
tracheostomy?

sterile hydrogen peroxide

what should a pt on
suicide precautions be
told to do?

sign a no harm contract aka no

suicide contract

196.

avoid caffeine due to tachycardia

what should the

nurse consider
when using an
interpreter?

the nurse should ensure that the

interpreter and the pt speak the
same dialect and share similar
cultural norms and practices

what to avoid with

theophylline
(theochron)?

197.

what would you see

with dehydration?

low potassium levels

what should a pt
with leukemia and
stomatitis eat?

a cold, soft, bland, and liquid foods to

prevent further irritation to the oral
mucosa
exa: oatmeal and applesauce

198.

how can hep B be

contracted?

blood transfusion
sexual contact
sharing IV drug needles

199.

what are the risks for

colorectal cancer?

obesity
high consumption of alcohol
cigarette smoking
high protein diet (red meat)
fam hx of colon cancer
hx of gastrectomy and IBS

200.

what are right sided

heart failure s/s?

edema
ascites
anorexia

201.

what are left sided

heart failure s/s?

dizziness

202.

following rupture of
the membranes what
is the greatest risk?

fecal cord compression of prolapse,

which is a medical emergency and
obtaining a fetal heart tone is
priority

203.

what should be done

to a pt with anxiety?

they will have trouble

concentrating therefore the nurse
should speak to the pt using
simple sentenses

204.

what is a
manifestation of type
2 DM?

infection and poor wound healing

205.

what to monitor with

timolol (Timoptic)?

a decreased in BP

182.

183.

184.

185.

186.

what should the

nurse do after a pt
has have a ECT
electroconvulsive
therapy?

the pt should be reoriented

frequently

187.

nursing
interventions for pts
in hypovolemic
shock?

place pt in trendelengurg position

elevate legs to promote venous
return to heart
increase IV fluids
keep pt warm

nursing
interventions for pts
with vein ligation
and stripping?

elevate feet (recliner is appropriate)

perform ROM
walk 5 to 10 min/hr while awake for
first 24 hrs
the nurse should wrap legs with an
elastic bandage for prevention of
clots

188.

189.

when would a pt on
antidepressant
(amitriptiline) feel
the effect?

10-14 days and experience full effect

for 4-8 weeks

206.

what is inhibit with spinal

cord damage at T1 and T2?

it inhibits function below the

waist

221.

what should pt with

cystic fibrosis eat?

a diet high in calories

207.

wheel chair precautions?

use a gell- filled seat cushion

limit time to 2 hours at a time
avoid donut-shaped pads
shift weight every 15 minutes

222.

what can long term

use of
corticosteroids
induced?

osteoporosis

208.

what kind of mask should

pt with COPD use?

a venturi mask

223.

administer a 0.9 % sodium chloride

becauses it replaces sodium looses

209.

what is priority in a child

with sickle cell crisis?

oxygenation

what should be
priority when a pt
with ketoacidosis
come to hospital?

210.

what should be avoided

with a mastectomy?

avoid raising elbow above the

shoulder until drain are
removed
avoid abduction
return to work in 4 to 6 wks
resume driving in 7 to 10 days

224.

what is the greatest

risk with a
thyroidectomy?

hypocalcemia leading to tetany by

s/s of tingling around mouth

225.

what is a s/s of
circulatory over
load?

crackles, sob, jugular vein distention,

cough

226.

when taking care of

a pt with meningitis
what should the
nurse wear?

a surgical mask within 3 feet ot the pt

to prevent exposure

227.

where would a pt
with acute
cholecystitis feel
pain?

RUQ radiating to back

228.

what to do first
when IV pump is
alarming?

observe the IV site for phlebitis

229.

what should pt
avoid before a
colonoscopy?

NSAIDs because it increases risk for

bleeding

230.

when should a
newborn repeat the
hearing test if they
fail the first time?

in 3 months

231.

what helps pt with

acute manic?

step by step direction

232.

what is scleroderma?

is a chronic disease with skin

changes causes thickening,
hardening, or tightening of the skin,
blood vessels, and internal organs

233.

what is s/s of herpes

zoster (shingles)?

results from reactivation of a

dormant varicella virus,
inflammation of the dorsal root
ganglion.
localized vesicular lesions unilateral
localized, nodular skin lesions

234.

genital herpes s/s?

fluid-filled vesicular rash in genital

region

235.

hepatitis A?

fecal-oral route, uncooked food

211.

during the initial tx of

acute diverticulitis what is
done?

the pt receives parenteral

nutrition and should be kept
NPO

212.

what do do for a child

with juvenile idiopathic
arthiritis?

use heat therapy prior to

physical activities because it
promotes exercise
they should attend school as
much as possible
promote exercise
eat a well balanced diet

213.

how often is a tetanus

booster recommended?

every ten years

214.

what to give prior to an

NST?

administer 4 oz (120 ML) of

orange juice to stimulate fetal
movement

215.

where should a cane be

placed?

held in the hand of the

stronger side of body

216.

what is priority in a pt
with anorexia nervosa?

record amount of food pt

consumes
weight daily
restrict exercing

217.

nitroglycerin (nitrostat)?

take up to 3 tabs during single

episode
place under tongue
store in original container
discard on expiration date

218.

how should epoiten alfa

be given?

sub Q

219.

how should IM injections

be given?

z tract method

220.

what promotes drainage

of stomach content in
tubes/pumps?

turning pt every two hours

236.

what is
raynaud
disease?

a disorder of the blood vessel that supply

blood to the skin and causes the distal
extremities and the tip of nose and ear to
feel numb/cool in response to cold temps or
stress s/s: tingling, swelling, painful
throbbing attacks may last mins to hours

251.

what are early

manifestations of
aids?

persistent fever
swollen glands
diarrhea
weight loss
fatigue

252.

what does an
elevated GFR
indicate?

an acute inflammatory process

pt will need thermal interventions
(heat or cold)

the pt should not smoke

237.

IGA?

associated with autoimmune diseases or

chronic infections

253.

what is an initial s/s

of wound infection?

erythema (redness) at incision site

238.

IGE?

allergic manifestations, anaphylaxis, and

asthma

254.

what is karposi
sarcoma KS?

239.

IGM?

antibodies against ABO blood groups

associated with aids it looks like

hyperpigmented multicentric lesions
that can be firm, flat, or nodular

240.

IgG?

antibodies to all types of infections

255.

241.

what should
the pt with
SLE skin
lesions do?

it affects any organ in the body is a chronic

autoimmune disorder, pt should monitor
body temp and report any elevations
promptly
apply moisturizer after bathing the lesions
with warm water

what does histamine

release causes?

increases mucus secretions

bronchospasms
bronchial constriction

256.

what should a pt
with active TB been
transported wear?

a mask

257.

what is early lyme

disease
characterized by?

fever
influenza like manifestation
erythema migrans
distinct progressive circular rash (or
bulls eye rash)

258.

can pts with

hepatitis a donate
blood?

no

259.

what does serum

amylase has to do
with?

pancreatitis

260.

stoma care?

use mild soap

apply skin sealant
cut it 1/8 to 1/16 larger than the size
measure it at least once a week

261.

what is a early s/s of

hepatitis A?

anorexia

262.

what is a late s/s of

hepatitis A?

pale feces
dark urine
jaundice

263.

what to eat with

peptic ulcer?

no soda
eat as normal as possible
eat 5-6 small meals a day

264.

what foods to avoid

with diverticulitis?

corn, strawberries, whole grain

bread

265.

what to do with
spleenectomy?

promoting lung aeration is important

266.

what is the position

for an enema?

left lateral

242.

what reduces
exposure to
allergens?

use a dehumidifier/ NOT humidifier

no carpet
bed linens should be washed weekly in hot
water
dont apply repellent to skin

243.

what is pcp
(pneumocystis
carininii
pneumonia?

it exist as part of the normal flora of the

lungs, the infection results from an
impaired immune system
pt may need a bronchoscopy with biopsy of
lung tissue

244.

eosinophils?

usually with asthma

245.

monocytes?

infection and several collagen disorders

246.

lymphocytes?

cancers and malnourished pts

247.

neutrophils?

infection, stress, and inflammation

248.

RA s/s?

bilateral pain and swelling in fingers and

joints with stiffness in morning, finger joints
are erythematous and warm to touch

249.

250.

how to handle
of an infant
with HIV?

what should
the pt with a
desentization
injection do?

use disposable diapers, and discard in

separate plastic bags
use bleach solution and gloves to clean up
blood spills
hand washing is important
anyone changing babies diaper should
wear gloves
must remain in clinic atleast 30 minutes

267.

TPN?

withdrawal look out for hypoglycemia

(shakiness and diaphoresis)

268.

SIADH?

is caused by excessive release of an

antidiuretic hormone (ADH) as a result
pt retains water creating a dilutional
hyponatremia

269.

270.

271.

what are dm type

2 manifestations
of
hyperglycemia?

increased urination and thirst

what are dm type

2 manifestations
of hypoglycemia?

tremors
cold, clammy skin

graves disease s/s?

difficulty slepping, diarrhea, increased

appetite, heat intolerance

282.

what is primary
therapy for a pt with
JRA?

preservation of joint function

283.

what is splitting?

a primitive ego defense

mechanism that places people in
good/bad categories

284.

what is displacement?

transfer of feelings to a less

threatening person

285.

what is
intellectualization?

a logical aproach

286.

what is projection?

attribute her faults to others

287.

what is the play mode

in toddlers?

parallel play with each child

performing similar activities

288.

when are liver enzymes

elevated?

in pts with HELLP

289.

what to do with
magnesium toxicity?

give calcium gluconate

s/s of toxicity: loss of deep tendon
reflex
respiratory depression
oliguria
if left untreated can lead to
cardiac and respiratory arrest

290.

when taking iron

supplement what
would counteract with
constipation?

eating raw fruit and vegetables

what does
ketoacidosis
causes?

dehydration by s/s of n/v

273.

what are early s/s

of hypoglycemia?

drowsiness
clammy skin
diaphoresis
blurred vision

274.

what are early s/s

of
hyperglycemia?

anorexia
dry mouth
urinary frequency

275.

what are s/s of

diabetes
insipidus?

polydipsia
polyuria

291.

s/s of coarctation of
the aorta?

unequal upper and lower

extremity pulses

276.

what does
parathyroid
hormone
regulates?

calcium

292.

SSRI Side effects

Side effects of SSRIs may include,

among others:

277.

what is the
common cause of
hyperthyroidism?

graves disease

278.

what are s/s of

thyroid storm?

fever
hypertension
pain
tachycardia

279.

what are s/s of

diabetic
ketoacidosis?

increased blood glucose levels

positive urine acetone
a low bicarbonate levels

280.

what causes
acromegaly?

excessive production of somatropin

(growth hormone) after closing of the
epiphyses

281.

what is addisons
disease?

hormone deficiency caused by damage

to the outer layer of the adrenal gland
they need diet high in salt, carbs, and
protein
low in potassium

272.

Nausea
Nervousness, agitation or
restlessness
Dizziness
Reduced sexual desire or
difficulty reaching orgasm or
inability to maintain an erection
(erectile dysfunction)
Drowsiness
Insomnia
Weight gain or loss
Headache
Dry mouth
Vomiting
Diarrhea

293.

MAOI Side
effects

The most common side effects of MAOIs

include:
Dry mouth
Nausea, diarrhea or constipation
Headache
Drowsiness
Insomnia
Skin reaction at the patch site
Dizziness or lightheadedness
Other possible side effects include:
Involuntary muscle jerks
Low blood pressure
Reduced sexual desire or difficulty reaching
orgasm
Sleep disturbances
Weight gain
Difficulty starting a urine flow
Muscle aches
Prickling or tingling sensation in the skin
(paresthesia

294.

Opioid

Other side effects of opioid analgesics include:

Euphoria, dysphoria, agitation, seizures,
hallucinations
Lowered blood pressure and heart rate
Muscular rigidity and contractions
Nausea and vomiting
Non-allergic itching
Pupil constriction
Sexual dysfunction
Urinary retention

295.

Do not
delegate

What you can EAT E-evaluate A-assess T-teach

296.

Addison's &
Cushings

Addison's = down down down up down

Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension,
blood volume, hypo/hyperkalemia,
hypo/hyperglycemia

297.

Better
peripheral
perfusion?

EleVate Veins, DAngle Arteries

298.

APGAR

Appearance (all pink, pink and blue, blue

(pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)

299.

Airborne
precautions

My chicken hez tb (measles, chickenpox

(varicella) Herpes zoster/shingles TB

300.

Airborne
precautions
protective
equip

private room, neg pressure with 6-12 air

exchanges/hr mask N95 for TB

301.

Droplet
precautions

spiderman! sepsis, scarlet fever,

streptococcal pharyngitis, parvovirus,
pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or
meningeal pneumonia, adeNovirus
(Private room or cohort mask!)

302.

Contact
precaution

MRS WEE
Multidrug resistant organism
Rresiratory infection
Skin infection
Wound infection
Enteric infection (C diff)
Eye infection (conjunctivitis)

303.

Skin infection

VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies

304.

Air or
Pulmonary
Embolism

S/S chest pain, dyspnea, tachycardia,

pale/cyanotic, sense of impending doom.
(turn pt to LEFT side and LOWER the head
of bed.)

305.

Woman in
labor (unreassuring FHR)

(late decels, decreased variability, fetal

bradycardia, etc) Turn pt on Left side, give
O2, stop pitocin, Increase IV fluids!

306.

Tube feeding
with decreased
LOC

Pt on Right side (promotes emptying of the

stomach) Head of bed elevated (prevent
aspiration)

307.

After lumbar
puncture and
oil based
myelogram

pt is flat SUPINE (prevent headache and

leaking of CSF)

308.

Pt with heat
stroke

flat with legs elevated

309.

during
Continuous
Bladder
Irrigation (CBI)

catheter is taped to the thigh. leg must be

kept straight.

310.

After
Myringotomy

position on the side of AFFECTED ear,

allows drainage.

311.

After Cateract
surgery

pt sleep on UNAFFECTED side with a night

shield for 1-4 weeks

312.

after Thyroidectomy

low or semi-fowler's position,

support head, neck and
shoulders.

327.

Shock

bedrest with extremities elevated 20

degrees. knees straight, head slightly
elevated (modified Trendelenberg)

313.

Infant with Spina Bifida

Prone so that sac does not

rupture

328.

Head Injury

elevate HOB 30 degrees to decrease ICP

329.

314.

Buck's Traction (skin)

elevate foot of bed for counter

traction

turn pt from side to side BEFORE

checking for kinks in tubing

315.

After total hip

replacement

don't sleep on side of surgery,

don't flex hip more than 45-60
degress, don't elevate Head Of
Bed more than 45 degrees.
Maintain hip abduction by
separating thighs with pillows.

Peritoneal
Dialysis (when
outflow is
inadequate)

330.

Lumbar
Puncture

After the procedure, the pt should be

supine for 4-12 hours as prescribed.

331.

Myesthenia
Gravis

worsens with exercise and improves with

rest

332.

Myesthenia
Gravis

a positive reaction to Tensilon---will

improve symptoms

333.

Cholinergic
Crisis

Caused by excessive medication ---stop

giving Tensilon...will make it worse.

334.

Liver biopsy
(prior)

must have lab results for prothrombin

time

335.

Myxedema/
hypothyroidism

slowed physical and mental function,

sensitivity to cold, dry skin and hair.

336.

Grave's Disease/
hyperthyroidism

accelerated physical and mental

function. Sensitivity to heat. Fine/soft
hair.

337.

Thyroid storm

increased temp, pulse and HTN

338.

PostThyroidectomy

semi-fowler's. Prevent neck

flexion/hyperextension. Trach at bedside

339.

Hypoparathyroid

CATS---Convulsions, Arrhythmias,
Tetany, Spasms, Stridor. (decreased
calcium) give high calcium, low
phosphorus diet

340.

Hyperparathyroid

fatigue, muscle weakness, renal calculi,

back and joint pain (increased calcium)
give a low calcium high phosphorous diet

341.

Hypovolemia

increased temp, rapid/weak pulse,

increase respiration, hypotension,
anxiety. Urine specific gravity >1.030

342.

Hypervolemia

bounding pulse, SOB, dyspnea,

rales/crackles, peripheral edema, HTN,
urine specific gravity <1.010. semi fowler's

343.

Diabetes
insipidus
(decreased ADH)

excessive urine output and thirst,

dehydration, weakness, administer
Pitressin

344.

SIADH (increased
ADH)

change in LOC, decreased deep tendon

reflexes, tachycardia. N/V HA administer
Declomycin, diuretics

345.

hypokalemia

muscle weakness, dysrhythmias,

increase K (rasins bananas apricots,
oranges, beans, potatoes, carrots, celery)

316.

Prolapsed cord

Knee to chest or Trendelenburg

oxygen 8 to 10 L

317.

Cleft Lip

position on back or in infant seat

to prevent trauma to the suture
line. while feeding hold in
upright position.

318.

To prevent dumping
syndrome

(post operative ulcer/stomach

surgeries) eat in reclining
position. Lie down after meals
for 20-30 min. also restrict fluids
during meals, low CHO and
fiber diet. small, frequent meals.

AKA (above knee

amputation)

elevate for first 24 hours on

pillow. position prone daily to
maintain hip extension.

320.

BKA (below knee

amputation)

foot of bed elevated for first 24

hours. position prone to provide
hip extension.

321.

detached retina

area of detachment should be

in the dependent position

322.

administration of enema

pt should be left side lying

(Sim's) with knee flexed.

323.

After supratentorial
surgery

(incision behind hairline on

forhead) elevate HOB 30-40
degrees

324.

After infratentorial
surgery

(incision at the nape of neck)

position pt flat and lateral on
either side.

325.

During internal radiation

on bed rest while implant in

place

326.

Autonomic
Dysreflexia/Hyperreflexia

S/S pounding headache,

profuse sweating, nasal
congestion, chills, bradycardia,
hypertension. Place client in
sitting position (elevate HOB)
FIRST!

319.

346.

Hyperkalemia

MURDER Muscle weakness, Urine

(olig, anuria) Resp depression,
decreased cardiac contractility, ECG
changes, reflexes

347.

Hyponatremia

nausea, muscle cramps, increased

ICP, muscular twitching, convulsions.
give osmotic diuretics (Mannitol) and
fluids

348.

349.

350.

Hypernatremia

Hypocalcemia
Hypercalcemia

358.

Autonomic
Dysreflexia

(potentially life threatening emergency!) HOB

elevate 90 degrees, loosen constrictive clothing,
assess for full bladder or bowel impaction,
(trigger) administer antihypertensives (may
cause stroke, MI, seizure)

359.

FHR
patterns
for OB

Think VEAL CHOP!

V-variable decels; C- cord compression caused
E-early decels; H- head compression caused
A-accels; O-okay, no problem
L- late decels; P- placental insufficiency, can't fill

360.

CATS Convulsions, Arrythmias,

Tetany, spasms and stridor

what to
check with
pregnancy

Never check the monitor or machine as a first

action. Always assess the patient first. Ex.. listen
to fetal heart tones with stethoscope.

361.

muscle weakness, lack of

coordination, abdominal pain,
confusion, absent tendon reflexes,
shallow respirations, emergency!

Position of
the baby by
fetal heart
sounds

Posterior --heard at sides

Anterior---midline by unbilicus and side
Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.

362.

Ventilatory
alarms

HOLD
High alarm--Obstruction due to secretions,
kink, pt cough etc
Low alarm--Disconnection, leak, etc

increased temp, weakness,

disorientation, dilusions,
hypotension, tachycardia. give
hypotonic solution.

351.

Hypo Mg

Tremors, tetany, seizures,

dysthythmias, depression, confusion,
dysphagia, (dig toxicity)

352.

Hyper Mg

depresses the CNS. Hypotension,

facial flushing, muscle weakness,
absent deep tendon reflexes,
shallow respirations. EMERGENCY

363.

ICP and
Shock

ICP- Increased BP, decreased pulse, decreased

resp
Shock--Decreased BP, increased pulse,
increased resp

353.

Addison's

Hypo Na, Hyper K, Hypoglycemia,

dark pigmentation, decreased
resistance to stress fx, alopecia,
weight loss. GI stress.

364.

Cor
pumonae

Right sided heart failure caused by left

ventricular failure (edema, jugular vein
distention)

365.

Heroin
withdrawal
neonate

irritable, poor sucking

366.

brachial
pulse

pulse area on an infant

367.

lead
poisoning

test at 12 months of age

368.

Before
starting IV
antibiotics

obtain cultures!

369.

pt with
leukemia
may have

epistaxis due to low platelets

370.

when a pt
comes in
and is in
active
labor

first action of nurse is to listen to fetal heart

tones/rate

371.

for phobias

use systematic desensitization

354.

Cushings

Hyper Na, Hypo K, hyperglycemia,

prone to infection, muscle wasting,
weakness, edema, HTN, hirsutism,
moonface/buffalo hump

355.

Addesonian crisis

N/V confusion, abdominal pain,

extreme weakness, hypoglycemia,
dehydration, decreased BP

356.

Pheochromocytoma

hypersecretion of epi/norepi.
persistent HTN, increased HR,
hyperglycemia, diaphoresis, tremor,
pounding HA; avoid stress, frequent
bathing and rest breaks, avoid cold
and stimulating foods (surgery to
remove tumor)

357.

Tetrology of Fallot

DROP (Defect, septal, Right

ventricular hypertrophy, Overriding
aortas, Pulmonary stenosis)

372.

373.

NCLEX answer tips

ARDS and DIC

choose assessment first! (assess,

collect, auscultate, monitor, palpate)
only choose intervention in an
emergency or stress situation. If the
answer has an absolute, discard it.
Give priority to the answers that
deal with the patient's body, not
machines, or equipment.

390.

1 tsp

5 mL

391.

1 oz

30 mL

392.

1 cup

8 oz

393.

1 quart

2 pints

394.

1 pint

2 cups

395.

1 g (gram)

1000 mg

are always secondary to another

disease or trauma

396.

1 kg

2.2 lbs

397.

I lb

16 oz

398.

centigrade to
Fahrenheit
conversion

F= C+40 multiply 5/9 and subtract 40

C=F+40 multiply 9/5 and subtract 40

399.

Angiotenson
II

In the lungs...potent vasodialator,

aldosterone attracts sodium.

400.

Iron toxicity
reversal

deferoxamine

401.

S3 sound

normal in CHF. Not normal in MI

402.

After
endoscopy

check gag reflex

403.

TPN given in

subclavian line

404.

pain with
diverticulitis

located in LLQ

405.

appendicitis
pain

located in RLQ

406.

Trousseau
and
Chvostek's
signs
observed in

Hypocalcemia

407.

never give K+
in

IV push

408.

DKA is rare

in DM II (there is enough insulin to prevent

fat breakdown)

409.

Glaucoma
patients lose

peripheral vision.

410.

Autonomic
dysreflexia

patients with spinal cord injuries are at risk

for developing autonomic dyreflexia (T-7 or
above)

411.

Spinal shock
occurs

immediately after injury

412.

multiple
sclerosis

myelin sheath destruction. disruptions in

nerve impulse conduction

413.

Myasthenia
gravis

decrease in receptor sites for acetylcholine.

weakness observed in muscles, eyes
mastication and pharyngeal musles. watch
for aspiration.

414.

Gullian -Barre
syndrome

ascending paralysis. watch for respiratory

problems.

374.

In an emergency

patients with a greater chance to

live are treated first

375.

Cardinal sign of ARDS

hypoxemia

376.

Edema is located

in the interstitial space, not the

cardiovascular space (outside of the
circulatory system)

377.

the best indicator of

dehydration?

weight---and skin turgor

378.

heat/cold

hot for chronic pain; cold for accute

pain (sprain etc)

379.

When pt is in
distress....medication
administration

is rarely a good choice

pneumonia

fever and chills are usually present.

For the elderly confusion is often
present.

381.

before IV antibiotics?

check allergies (esp. penicillin) make

sure cultures and sensitivity has
been done before first dose.

382.

COPD and O2

with COPD baroreceptors that

detect CO2 level are destroyed,
therefore, O2 must be low because
high O2 concentration takes away
the pt's stimulation to breathe.

380.

383.

Prednisone toxicity

Cushings (buffalo hump, moon

face, high blood sugar, HTN)

384.

Neutropenic pts

no fresh fruits or flowers

385.

Chest tubes are

placed

in the pleural space

386.

Preload/Afterload

Preload affects the amount of blood

going into Right ventricle. Afterload
is the systemic resistance after
leaving the heart.

387.

CABG

Great Saphenous vein in leg is

taken and turned inside out
(because of valves inside) . Used for
bypass surgery of the heart.

388.

Unstable Angina

not relieved by nitro

389.

PVC's

can turn into V fib.

415.

TIA

transient ischemic attack....mini stroke,

no dead tissue.

437.

bethamethasone
(celestone)

surfactant. premature babies

416.

CVA

cerebriovascular accident. brain tissue

dies.

438.

milieu therapy

taking care of pt and environmental

therapy

417.

Hodgkin's disease

cancer of the lymph. very curable in

early stages

439.

cognitive therapy

counseling

440.

418.

burns rule of Nines

head and neck 9%

each upper ext 9%
each lower ext 9%
front trunk 18%
back trunk 18%
genitalia 1%

five interventions
for psych patients

safety
setting limits
establish trusting relationship
meds
least restrictive methods/environment

441.

SSRI's

take about 3 weeks to work

442.

patients with
hallucinations
patients with
delusions

redirect them
distract them

443.

Thorazine and
Haldol

can cause EPS

444.

Alzheimer's

60% of all dementias, chronic,

progressive degenerative cognitive
disorder.

419.

birth weight

doubles by 6 months
triples by 1 year

420.

if HR is <100
(children)

Hold Dig

421.

early sign of cystic

fibrosis

meconium in ileus at birth

422.

Meningitis--check
for

Kernig's/ brudinski's signs

423.

wilm's tumor

encapsulated above kidneys...causes

flank pain

445.

draw up regular
and NHP?

Air into NHP, air into Regular. Draw

regular, then NHP

424.

hemophilia is x
linked

passed from mother to son

446.

Cranial nerves

425.

when phenylaline
increases

brain problems occur

426.

buck's traction

knee immobility

427.

russell traction

femur or lower leg

428.

dunlap traction

skeletal or skin

429.

bryant's traction

children <3 y <35 lbs with femur fx

430.

eclampsia is

a seizure

431.

perform
amniocentesis

before 20 weeks to check for cardiac

and pulmonary abnormalities

S=sensory M=motor B=both

Oh (Olfactory I) Some
Oh (Optic II ) Say
Oh (Oculomotor III) Marry
To (trochlear IV) Money
Touch (trigeminal V) But
And (Abducens VI ) My
Feel (facial VII) Brother
A (auditory VIII) Says
Girl's (glossopharyngeal IX) Big
Vagina (vagus X) Bras
And (accessory XI) Matter
Hymen (Hypoglossal XII) More

Rh mothers receive
Rhogam

to protect next baby

447.

432.

Hypernatremia

433.

anterior fontanelle
closes
by...posterior by..

18 months, 6-8 weeks

S (Skin flushed)
A (agitation)
L (low grade fever )
T (thirst)

448.

Developmental

434.

caput
succedaneum

diffuse edema of the fetal scalp that

crosses the suture lines. reabsorbes
within 1 to 3 days

435.

pathological
jaundice occurs:
physiological
jaundice occurs:

before 24 hours (lasts 7 days)

after 24 hours

2-3 months: turns head side to side

4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a
cup

449.

Hepatitis A

Ends in a vowel, comes from the bowel

450.

Hepatitis b

placenta previa s/s

placental abrution
s/s

there is no pain, but there is bleeding

there is pain, but no bleeding (board
like abd)

B= blood and body fluids (hep c is the

same)

451.

Apgar measures

HR RR Muscle tone, reflexes, skin color.

Each 0-2 points. 8-10 ok, 0-3 resuscitate

436.

452.

Glasgow
coma scale

eyes, verbal, motor

Max- 15 pts, below 8= coma

453.

Addison's
disease:
Cushing's
syndrome:

"add" hormone
have extra "cushion" of hormone

Dumping
syndrome

increase fat and protein, small frequent

meals, lie down after meal to decrease
peristalsis. Wait 1 hr after meals to drink

Disseminated
herpes zoster
localized
herpes zoster

Disseminated herpes=airborne precautions

Localized herpes= contact precautions. A
nurse with localized may take care of
patients as long as pts are not
immunosuppressed and the lesions must be
covered!

456.

Isoniazid

causes peripheral neuritis

457.

Weighted NI
(naso
intestinal
tubes)

Must float from stomach to intestine. Don't

tape right away after placement. May leave
coiled next to pt on HOB. Position pt on
RIGHT to facilitate movement through
pyloris

458.

Cushings
ulcers

r/t brain injury

459.

Cushing's
triad

r/t ICP (HTN, bradycardia, irritability, sleep,

widening pulse pressure)

460.

Thyroid
storm

HOT (hyperthermia)

461.

Myxedema
coma

COLD (hypothermia)

462.

Glaucoma

No atropine

463.

Non Dairy
calcium

Rhubarb sardines collard greens

464.

Koplick's
spots

prodomal stage of measles. Red spots with

blue center, in the mouth--think kopLICK in
the mouth

465.

INH can
cause
peripheral
neuritis

Take vitamin B6 to prevent. Hepatotoxic

466.

pancreatitis
pts

put them in fetal position, NPO, gut rest,

Prepare anticubital site for PICC, they are
probably going to get TPN/Lipids

467.

Murphy's sign

Pain with palplation of gall bladder (seen

with cholecystitis)

468.

Cullen's sign

469.

Turner's sign

454.

455.

470.

McBurney's point

Pain in RLQ with appendicitis

471.

LLQ

Diverticulitis

472.

RLQ

appendicitis watch for peritonitis

473.

Guthrie test

Tests for PKU. Baby should have eaten

protein first

474.

shilling test

Test for pernicious anemia

475.

Peritoneal
dialysis

Its ok to have abd cramps, blood tinged

outflow and leaking around site if the
cath (tenkoff) was placed in the last 1-2
weeks. Cloudy outflow is never ok

476.

Hyper reflexes
absent reflexes

upper motor neuron issue (your

reflexes are over the top)
Lower motor neuron issue

477.

Latex allergies

assess for allergies to bananas, apricots,

cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes and
peaches

478.

Tensilon

used in myesthenia gravis to confirm

diagnosis

479.

ALS

(amyotrophic lateral sclerosis)

degeneration of motor neurons in both
upper and lower motor neuron systems

480.

Transesophageal
fistula

esophagus doesn't fully develop. This is

a surgical emergency (3 signs in
newborn: choking, coughing, cyanosis)

481.

MMR

is given SQ not IM

482.

codes for pt care

Red- unstable, ie.. occluded airway,

actively bleeding...see first
Yellow--stable, can wait up to an hour for
treatment
Green--stable can wait even longer to be
seen---walking wounded
Black--unstable, probably will not make
it, need comfort care
DOA--dead on arrival

483.

Contraindication
for Hep B vaccine

anaphylactic reaction to baker's yeast

484.

what to ask
before flu shot

allergy to eggs

485.

what to ask
before MMR

allergy to eggs or neomycin

486.

when on
nitroprusside
monitor:

cyanide. normal value should be 1.

ecchymosis in umbilical area, seen with

pancreatitis

487.

William's
position

semi Fowler's with knees flexed to

reduce low back pain

Flank--greyish blue. (turn around to see

your flanks) Seen with pancreatitis

488.

S/S of hip fx

External rotation, shortening adduction

489.

Fat embolism

blood tinged sputum r/t inflammations.

Increase ESR, respiratory alkalosis.
Hypocalcemia, increased serum lipids.

complications
of mechanical
ventilation

pneumothorax, ulcers

491.

Paget's disease

tinnitus, bone pain, elnargement of bone,

thick bones

492.

with
allopurinol

no vitamin C or warfarin!

493.

IVP requires

bowel prep so bladder can be visualized

494.

acid ash diet

cheese, corn, cranberries, plums, prunes,

meat, poultry, pastry, bread

495.

alk ash diet

milk, veggies, rhubarb, salmon

496.

orange tag in
psych

is emergent psych

497.

thyroid med
side effects

insomnia. body metabolism increases

498.

Tidal volume
is

7-10 ml/kg

499.

COPD patients
and O2

2LNC or less. They are chronic CO2

retainers expect sats to be 90% or less

500.

Kidney
glucose
threshold

180

501.

Stranger
anxiety is
greatest at
what age?

7-9 months..separation anxiety peaks in

toddlerhood

502.

when drawing
an ABG

put in heparinized tube. Ice immediately,

be sure there are no bubbles and label if pt
was on O2

490.

503.

Munchausen
syndrome vs
munchausen
by proxy

Munchausen will self inflict injury or illness

to fabricate symptoms of physical or mental
illness to receive medical care or
hospitalization. by proxy mother or other
care taker fabricates illness in child

504.

multiple
sclerosis

motor s/s limb weakness, paralysis, slow

speech. sensory s/s numbness, tingling,
tinnitis cerebral s/s nystagmus, atazia,
dysphagia, dysarthia

505.

hungtington's

50% genetic autosomal dominanat

disorder.. s/s uncontrolled muscle
movements of face, limbs and body. no cure

506.

WBC left shift

pt with pyelo. neutrophils kick in to fight

infections

507.

pancreatic
enzymes are
taken

with each meal!

508.

infants IM site

Vastus lateralis

509.

Toddler 18
months+ IM
site

Ventrogluteal

510.

IM site for
children

deltoid and gluteus maximus

511.

Thoracentesis:

position pt on side or over bed table. no

more than 1000 cc removed at a time. Listen
for bilateral breath sounds, V.S, check
leakage, sterile dressing

512.

Cardiac cath

NPO 8-12 hours. empty bladder, pulses, tell

pt may feel heat, palpitations or desire to
cough with injection of dye. Post: V.S.--keep
leg straight. bedrest for 6-8 hr

513.

Cerebral angio
prep

well hydrated, lie flat, site shaved, pulses

marked. Post--keep flat for 12-14 hr. check
site, pulses, force fluids.

514.

lumbar
puncture

fetal position. post-neuro assess q15-30

until stable. flat 2-3 hour. encourage fluids,
oral analgesics for headache.

515.

ECG

no sleep the night before, meals allowed, no

stimulants/tranquilizers for 24-48 hours
before. may be asked to hyperventilate 3-4
min and watch a bright flashing light. watch
for seizures after the procedure.

516.

Myelogram

NPO for 4-6 hours. allergy hx

phenothiazines, cns depressants and
stimulants withheld 48 hours prior. Table
moved to various positions during test. Post-neuro assessment q2-4 hours, water
soluble HOB UP. oil soluble HOB down.
oralanalgesics for HA. No po fluids. assess
for distended bladder. Inspect site

517.

Liver biopsy

administer Vitamin K, NPO morning of exam

6 hrs. Give sedative. Teach pt to expect to
be asked to hold breath for 5-10 sec. supide
position, lateral with upper arms elevated.
Post--position on RIGHT side. frequent VS.
report severe ab pain STAT. no heavy lifting
1 wk

518.

Paracentesis

semi fowler's or upright on edge of bed.

Empty bladder. post VS--report elevated
temp. watch for hypovolemia

519.

laparoscopy

CO2 used to enhance visual. general

anesthesia. foley. post--ambulate to
decrease CO2 buildup

520.

PTB

low grade afternoon fever

521.

pneumonia

rusty sputum

522.

asthma

wheezing on expiration

523.

emphysema

barrel chest

524.

kawasaki
syndrome

strawberry tongue

553.

sickle cell crisis

two interventions to prioritize: fluids

and pain relief.

525.

pernicious
anemia

red beefy tongue

554.

glomuloneprhitis

the most important assessment is

blood pressure

526.

downs syndrome

protruding tongue

555.

children 5 and up

527.

cholera

rice watery stool

should have an explanation of what

will happen a week before surgery

528.

malaria

stepladder like fever--with chills

556.

Kawasaki disease

529.

typhoid

rose spots on the abdomen

(inflammation of blood vessles,

hence the strawberry tongue)
causes coronary artery aneurysms.

530.

diptheria

pseudo membrane formation

557.

531.

measles

koplick's spots

ventriculoperitoneal
shunt

532.

sle (systemic
lupus)

butterfly rash

533.

pyloric stenosis

olive like mass

534.

Addison's

bronze like skin pigmentation

535.

Cushing's

moon face, buffalo hump

watch for abdominal distention.

watch for s/s of ICP such as high
pitch cry, irritability and bulging
fontanels. In a toddler watch for loss
of appetite and headache. After
shunt is placed bed position is FLAT
so fluid doesn't reduce too rapidly. If
presenting s/s of ICP then raise the
HOB 15-30 degrees

536.

hyperthyroidism/
grave's disease

exophthalmos

558.

3-4 cups of milk a

day for a child?

537.

myasthenia gravis

descending musle weakness

NO too much milk can reduce the

intake of other nutrients especially
iron. Watch for ANEMIA

538.

gullian-barre
syndrome

ascending muscle weakness

559.

MMR and varicella

immunizaions

after 15 months!

539.

angina

crushing, stabbing chest pain relieved

by nitro

560.

cryptorchidism

540.

MI

crushing stabbing chest pain

unrelieved by nitro

undescended testicles! risk factor for

testicular cancer later in life. Teach
self exam for boys around age 12-most cases occur in adolescence

541.

cystic fibrosis

salty skin

561.

CSF meningitis

HIGH protein LOW glucose

542.

DM

polyuria, polydipsia,polyphagia

562.

no nasotracheal suctioning

543.

DKA

kussmal's breathing (deep rapid)

Head injury or skull

fx

563.

Bladder CA

painless hematuria

otitis media

feed upright to avoid otitis media!

544.

564.

545.

BPH

reduced size and force of urine

positioning for
pneumonia

546.

retinal
detachment

floaters and flashes of light. curtain

vision

547.

glaucoma

painful vision loss. tunnel vision. halo

lay on affected side, this will splint

and reduce pain. However, if you
are trying to reduce congestion, the
sick lung goes up! (like when you
have a stuffy nose and you lay with
that side up, it clears!)

548.

retino blastoma

cat's eye reflex

565.

for neutropenic pts

549.

increased ICP

hypertension, bradypnea,,
bradycarday (cushing's triad)

no fresh flowers, fresh fruits or

veggies and no milk

566.

shock

Hypotension, tachypnea, tachycardia

antiplatelet drug
hypersensitivity

bronchospasm

550.
551.

Lymes disease

bullseye rash

567.

bowel obstruction

552.

intraosseous
infusion

often used in peds when venous access

can't be obtained. hand drilled through
tibia where cryatalloids, colloids, blood
products and meds are administered
into the marrow. one med that CANNOT
be administered IO is isoproterenol, a
beta agonist.

more important to maintain fluid

balance than to establish a normal
bowel pattern (they cant take in oral
fluids)

568.

Basophils reliease
histamine

during an allergic response

569.

Iatragenic

means it was caused by treatment,

procedure or medication

570.

Tamoxifen

watch for visual changes--indicates toxicity

590.

Toddlers
need to
express

independence!

571.

post
spelectomy

pneumovax 23 is administered to prevent

pneumococcal sepsis

572.

Alkalosis/
Acidosis and K+

ALKalosis=al K= low sis. Acidosis (K+ high)

591.

Addison's

causes sever hypotension!

592.

pancreatitis

first pain relief, second cough and deep

breathe

No
phenylalanine

to a kid with PKU. No meat, dairy or

aspartame

593.

CF chief
concern?

Respiratory problems

never give
potassium

to a pt who has low urine output!

594.

take it to him/her first then take up the chain

characterized by massive proteinuria

caused by glomerular damage.
corticosteroids are the mainstay

a nurse
makes a
mistake?

nephrotic
syndrome

595.

the first sign of

ARDS

increased respirations! followed by

dyspnea and tachypnea

nitrazine
paper

turns blue with alkaline amniotic fluid. turns

pink with other fluids

596.

crutches first followed by good leg

normal PCWC
(pulmonary
capillary wedge
pressure)

is 8-13 readings 18-20 are considered high

up stairs with
crutches?

597.

dumping
syndrome?

use low fowler's to avoid. limit fluids

598.

TB drugs are

hepatotoxic!

578.

first sign of PE

sudden chest pain followed by dyspnea

and tachypnea

599.

clozapine,
Clozaril

antipsychotic
anticholinergic

579.

Digitalis

increases ventricular irritability ----could

convert a rhythm to v-fib following
cardioversion

600.

clozapine s/e

weight gain, hypotension, hyperglycemia,

agranulocytosis

Cold stress and

the newborn

biggest concern resp. distress

601.

580.

dehydration

-hypovolemia
- elevated urine specific gravity

Parathyroid
relies on

vitamin D to work

602.

581.

flumazenil,
Romazicon

benzo overdose

Glucagon
increases the
effects of?

anticoagulants

603.

582.

umbilical
cord
compression

reposition side to side or knee-chest

Sucking stab
wound

cover wound and tape on 3 sides to allow

air to escape. If you cover and occlude it--it
could turn into a closed pneumo or
tension pneumo!

604.

583.

short cord

discontinue pictocin

605.

Discontinue
oxypocin

584.

chest tube
pulled out?

occlusive dressing

585.

PE

Needs O2!

586.

DKA

acetone and keytones increase! once

treated expect postassium to drop! have
K+ ready

587.

Hirschprung's

diagnosed with rectal biopsy. S/S infantfailure to pass meconium and later the
classic ribbon-like/foul smelling stools

588.

Intussusception

Common in kids with CF. Obstruction may

cause fecal emesis, current jelly stools.
enema---resolution=bowel movements

Discontinue oxytocin if uterine

hyperstimulation occurs. Symptoms of
uterine
hyperstimulation include:
Contraction frequency more often than
every 2 min.
Contraction duration longer than 90
seconds.
Contraction intensity that results in
pressures greater than 90 mm Hg as shown
by IUPC.
Uterine resting tone greater than 20 mm
Hg between contractions.
No relaxation of uterus between
contractions

606.

Airborne
Precautions

My - Measles
Chicken - Chicken Pox/Varicella
Hez - Herpez Zoster/Shingles
TB

573.

574.

575.

576.

577.

589.

laboring mom's
water breaks?

first thing--worry about prolapsed cord!

607.

Droplet

think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal)
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
Private Room or cohort
Mask

608.

Contact

MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis

609.

Hypokalemia

muscle ewakness, dysrhythmias, increase

K (raisins, bananas, apricots, oranges,
beans, potatoes, carrots, celery)

610.

Hyperkalemia

muscle weakness, urine (oliguria/anuria),

respiratory depression,
decreased cardiac contractility, ECG
changes, reflexes

611.

Hyponatremia

nausea, muscle cramps, increased ICP,

muscular twitching, convulsion; osmotic
diuretics, fluids

612.

Hypernatremia

increased temp, weakness,

disorientation/delusions, hypotension,
tachycardia;
hypotonic solution

613.

MAOI

pirates say arrrr, so think; pirates take

MAOI's when they're
depressed.
- explanation; MAOI's used for depression
all have an arrr sound in the middle
(Parnate, Marplan, Nardil)

614.

FHR patterns

V = variable decels; C = cord compression

caused
E = early decels; H = head compression
caused
A = accels; O = okay, not a problem!
L = late decels = placental insufficiency,
can't fill

615.

Cord
Compression

place the mother in the TRENDELENBERG

position because this removes
pressure of the presenting part off the
cord. (If her head is down, the baby is no
longer being
pulled out of hte body by gravity)
If the cord is prolapsed, cover it with sterile
saline gauze to prevent drying of the cord
and to
minimize infection.

616.

Late
decelerations

turn the mother to her left side, to allow

more blood flow to the placenta

617.

ICP

increased BP, decreased pulse, decreased

resp

618.

shock

decreased BP, increased pulse, increased

resp

619.

Conversions

1 t (teaspoon)= 5 ml
1 T(tablespoon)= 3 t = 15 ml
1 oz= 30 ml
1 cup= 8 oz
1 quart= 2 pints
1 pint= 2 cups
1 gr (grain)= 60 mg
1 g (gram)= 1000 mg
1 kg= 2.2 lbs
1 lb= 16 oz

620.

Antidotes

heparin= protamine sulfate

coumadin= vitamin k
ammonia= lactulose
acetaminophen= n-Acetylcysteine.
Iron= deferoxamine
Digitoxin, digoxin= digibind.
Alcohol withdraw= Librium.

621.

Developmental

2-3 months: turns head side to side

4-5 months: grasps, switch & roll
6-7 months: sit at 6 and waves bye-bye
8-9 months: stands straight at eight
10-11 months: belly to butt (phrase has 10
letters)
12-13 months: twelve and up, drink from a
cup

622.

Hepatitis

Hepatitis: -ends in a VOWEL, comes from

the BOWEL (Hep A)
Hepatitis B=Blood and Bodily fluids
Hepatitis C is just like B

623.

Give NSAIDS,
Corticosteroids, drugs for
Bipolar, Cephalosporins,
and Sulfanomides

with food

624.

Valium is treatment of

status epilepticus (Ativan may

be used also)

625.

Allopurinol

Push fluids.
Avoide purines
Avoid Vit C and Warfarin

626.

Rifampin

Red orange tears and urine,

also contraceptives don't work
as well

627.

LLQ

diverticulitis , low residue, no

seeds, nuts, peas

628.

Kayexalate

Don't use with hypoactive

bowel sounds

629.

Anticholinergic effects

dry mouth==can't spit

urinary retention=can't ****
constipated =can't ****
blurred vision=can't see

630.

TCA end in mine, pine or

line

Therapeutic Uses
Depression
Depressive episodes of
bipolar disorders
--Side effects:
Orthostatic hypotension,
Anticholinergic effects,
Sedation, sweating, increased
chance of seizure
----Avoid use of MAOI and TCA
Avoid TCA and antihistamines

631.

SSRI (ends in
pram, tine,
line)

Therapeutic Uses
Major depression
Obsessive compulsive disorder
Bulimia nervosa
Premenstrual dysphoric disorders
Panic disorders
Posttraumatic disorder
--Decreased sex libido
CNS stimulation (inability to sleep, anxiety)
Weight loss / gain
Serotonin syndrome
Hyponatremia
GI bleeding
Bruxism (report to provider)
--Do not use St. Johns Wart
MAOI must be discontinued for 14 days
--May increase warfarin levels or NSAID
levels

632.

MAOI (zine,
zid, mine, line)

Therapeutic Uses
Atypical depression
Bulimia nervosa
Obsessive compulsive disorder
--------Side effects
CNS stimulation, orthostatic hypotension,
hypertensive crisis (with tyramine)
--------added effects with anti-hypertensives

633.

Welbutrin

Therapeutic Uses
Treatment of depression
Alternative to SSRIs for clients unable to
tolerate the sexual dysfunction side effects
Aid to quit smoking
Prevention of seasonal affective disorder
--Weight loss, sz, headache dry mouth